A personal experience of Patient Administration Systems, Coding and Information in the UK NHS. Charles Carson April 2008 Development of National Coding Standards within the Czech DRG System

What this discussion will cover:- Section 1  Introduction and overview of PAS  Modules of PAS – Patient Master Index etc. Section 2  System Set up  System Security  System Management Section 3  Information Culture  Turning “Data” into “Information” Section 4  How information is produced from PAS for building HRG’s Development of National Coding Standards within the Czech DRG System

What is a Patient Administration System (PAS)? A computerised administrative system used to manage and record patient demographic details and any treatments that the patient has, as an inpatient or outpatient. It is vital to effective operation and management of the hospital, generating such documents as labels and letters and providing information to monitor throughputs against contracts and report performance against key targets. Development of National Coding Standards within the Czech DRG System

Importance of PAS PAS is at the ‘heart’ of all other hospital patient management systems and is integrated with them to provide the ‘core’ demographic and local patient identifier details e.g. Radiology Systems, Laboratories, A&E Systems It provides management with information on service delivery as a ‘by product’ of its operational use. Development of National Coding Standards within the Czech DRG System

PAS Modules PAS is normally made up of various software modules each having a particular application with specific functions e.g. - Patient Master Index (PMI) - Recording clinical coding (KES) - Admitting, transferring and discharging patients (ADT) - Recording outpatient referrals and booking appointments (OPI) - Waiting list management (WL) - Bed management (IPL) - Casenote tracking (CNT) - Statistical analysis (STA) - System Management (AMS) - Order Communications (OCS) Development of National Coding Standards within the Czech DRG System

Patient Master Index This is the ‘core’ of the system and is a list of all patients known to the organisation Each patient will have a unique number on the system, linking all locally used numbers Patients can be identified using various search criteria Data includes demographics, General Practitioner details and next of kin details Development of National Coding Standards within the Czech DRG System

Patient Master Index (PMI) Development of National Coding Standards within the Czech DRG System

Admitting, transferring & discharging (ADT) Patients are admitted, transferred or discharged on the system and such details as dates of events, consultant and specialty, ward on admission/discharge,method of admission,method of discharge are recorded as part of this process. The system is updated in ‘real time’ Development of National Coding Standards within the Czech DRG System

Outpatients Management Module This module records everything from initial referral, to the patient being seen at the outpatient department: again capturing details such as dates of events, consultant and specialty,source of referral, clinical urgency and outcome of outpatient consultation Development of National Coding Standards within the Czech DRG System

Waiting List Module This module of PAS records details relating to patients waiting for inpatient or day case treatment. Details include date added to waiting list, consultant, specialty, clinical urgency and procedure to be carried out. Has been very political in the UK ! Development of National Coding Standards within the Czech DRG System

Clinical Coding This module of PAS records clinical coding using prescribed coding conventions i.e. ICD International Classification of Diseases and related health problems (Version 10) OPCS Surgical Operations and procedures (Fourth Revision) Development of National Coding Standards within the Czech DRG System

Example from PAS - Diagnosis Development of National Coding Standards within the Czech DRG System

Example from PAS - Operation Development of National Coding Standards within the Czech DRG System

Other Modules Bed management – used to track bed availability Casenote tracking Statistical Analysis – monthly/quarterly reports submitted to the MOH and purchasers System Management – setting up and maintaining users access and masterfiles,setting up patient letters,managing printing queues,fault reporting to software supplier Order Communications Development of National Coding Standards within the Czech DRG System

System structure PAS is structured in such a way that core masterfiles work across the whole range of modules. These masterfiles are compiled using local codes but structured to include such data items as regionally designated codes e.g. Specialty Codes For example, our local code for the Specialty of Urology is UROL but the MOH code is ‘101’ and so we must reflect this on our masterfile. Development of National Coding Standards within the Czech DRG System

Specialty Masterfile Development of National Coding Standards within the Czech DRG System

Other Masterfiles – to name a few! Diagnostic Codes (ICD10) Operation Codes (OPCS4) Consultant Code Specialty Codes Waiting List Codes Ward Codes Source of referral codes Method of admission codes Development of National Coding Standards within the Czech DRG System

Importance of regionally defined codes? So comparisons can be made, comparing like with like If medical or surgical services are transferred from one provider to another, eg. the whole service, or the workload / activity of an individual consultant can be tracked Development of National Coding Standards within the Czech DRG System

System security Security of PAS is of vital importance and significance due to the sensitive nature of the data being held, and the number of users who will require access: it is common to have several hundred accredited users at one hospital. Development of National Coding Standards within the Czech DRG System

Who has access to our systems? Nurses, Doctors, Administrative staff Development of National Coding Standards within the Czech DRG System

System Manager’s role Monitoring management and performance of the system- including backup procedures- to ensure it meets user requirements Controlling and ensuring accurate recording of data on system in keeping with MOH definitions and guidance Planning for, and implementing new hardware, software releases (scheduling down time etc.) Responsible for monitoring data security and confidentiality Submitting relevant statistical returns to the MOH for the organisation Development of National Coding Standards within the Czech DRG System

System Management 1. User administration (set up and maintaining accounts) 2. Maintaining system 3. Verify that peripherals are working properly 4. Quickly arrange repair for hardware in event of hardware failure 5. Monitor system performance 6. Ensure system supports/complements work flow processes 7. Oversee implementation of new software i.e. testing and sign off 8. Ensure backup and recover procedures are in place 9. Set up security policies for users Development of National Coding Standards within the Czech DRG System

The Information Culture Healthcare is an information-intensive business. So health managers in the UK have a responsibility to be able to access, analyse and report on a wide range on information produced by PAS and other databases. To provide the basis for well-informed decision making in both the clinical and managerial settings Development of National Coding Standards within the Czech DRG System

The Manager’s Role in Information Systems Planning : setting goals Organising Directing Monitoring: evaluating performance Controlling resources Continuous improvement Development of National Coding Standards within the Czech DRG System

Types of information used by Health Managers: at different levels. Strategic: conceptual and knowledge-based Tactical : human relations and information – based Operational : Technical and data-based. Development of National Coding Standards within the Czech DRG System

Many systems in UK NHS. Acute healthcare Clinical information Corporate information Primary care information Development of National Coding Standards within the Czech DRG System

Information Requirements Commissioning bodies, providers and MoH are all involved in planning health services in the UK Good planning needs information Development of National Coding Standards within the Czech DRG System

SMART Acronym used in UK Strategic Meaningful Accurate Relevant Timely Development of National Coding Standards within the Czech DRG System

The Challenge for the Manager Managers relying on Health Information need to: – Assess and analyse the information requirements of their organisation – Plan innovative and integrated solutions to meet those requirements – Empower and gain the interest of clinicians, and patients through the carefully managed implementation of health information systems Development of National Coding Standards within the Czech DRG System

The Challenge for the Manager (2) Continually and thoroughly evaluate the performance of the systems Make information effective Implant information as an integral part of delivering Healthcare throughout the Healthcare system To constantly develop further improvements to the systems. Development of National Coding Standards within the Czech DRG System

Main cultural change for us at the outstart Creating and sustaining a sharing environment, Realising that there are many “stakeholders” Learning to trust these other stakeholders Problem solving together Sharing solutions Getting away from data/ statistics to useable management information Development of National Coding Standards within the Czech DRG System

Major operational problems for us In 1989/ 90 when our process started, our PAS database was poor Coding was in its infancy, with little status. Data were therefore unreliable – so there was resistance / no “ownership” from doctors and nurses Our analytical skills were undeveloped Overabundance of hardware ‘solutions’ Software didn’t exist or was only being developed. Coders, Medical Records and Information staff were demotivated. Development of National Coding Standards within the Czech DRG System

Systems & Structures Managers should support and foster the coordinated and well-integrated developed “end-user” capacity. But maintain control of centralised and corporate systems. Maintain close involvement of medical and nursing staff: they need to have “ownership” of the systems too. Development of National Coding Standards within the Czech DRG System

Information Systems Basics (very!) Even a simple form such as a service quality questionnaire at McDonalds constitutes an information system The written data in the form are the “Input” The layout of the form restructures the data Then the restructured data are the “Output” when read by another person Development of National Coding Standards within the Czech DRG System

Data into Information Development of National Coding Standards within the Czech DRG System

How do you turn “data” into “information”? You start by restructuring the “Input” (data) into “Output” (information) What main types of “data” are collected by Commissioners, the Ministry, hospitals etc? Development of National Coding Standards within the Czech DRG System

I suggest 3 main categories, although there are others: Activity data: comes from PAS – what facilities were used? – how many patients used them? (Coding) – what sorts of patients were seen? ( Coding) Development of National Coding Standards within the Czech DRG System

Category 2 Manpower data: Not held in PAS – How many and what kinds of staff were involved in caring for different kinds of patient? Development of National Coding Standards within the Czech DRG System

Category 3 Financial data : Not held in PAS – How much money was spent – How it was spent: hospital departments, drugs, medications, facilities etc.. Development of National Coding Standards within the Czech DRG System

Information for HRGs Development of HRGs needs all three categories of information, but Only one category is held on PAS Development of National Coding Standards within the Czech DRG System

Other kinds of Data Sets Similar data from other districts, for comparison Population data, census statistics Data about catchment areas, bed complements and norms Data about family doctor services : maternity services, child health, family planning, etc. Development of National Coding Standards within the Czech DRG System

The basic data set which management needs, in a manner that it can use: So there are different versions of “Minimum Data Sets” The Contract Minimum Data Set (CMDS) is one of the key building blocks of management information in the hospital Development of National Coding Standards within the Czech DRG System

Data into Information When you have decided what should be the contents of your MDS: you can identify the components – specify the way in which you would like them presented – And use/train reliable information staff to pilot the first MDS. Development of National Coding Standards within the Czech DRG System

Information Culture again So you are on the threshold of your own “information culture” – Encouraging the education and training the data collectors, the clinical coders and the information users – Encouraging the involvement of everyone with an interest in data or information – Developing good administrative procedures to ensure that data about patients and staff are kept confidential – Continually testing and improving data quality Development of National Coding Standards within the Czech DRG System

Information Culture – Developing standards against which to check the accuracy and timeliness of the data production – Identifying the manpower and skills needed to provide an effective information service. – Willingness to share problems and solutions with others Development of National Coding Standards within the Czech DRG System

What HRGs have meant for us as a Provider Hospital in Ireland. Not currently used for invoicing, but will be vital when Payment by Results introduced in full in very near future. English service is further down the line than Ireland, or Scotland. At present used for comparative analysis by Purchasers and MOH to compare costs against other Providers Statutory requirement to provide information which will feed into HRG development We had to get used to the philosophy of sharing information, and collaborating with other stakeholders Development of National Coding Standards within the Czech DRG System

Information Technology Information technology can only be exploited to the full when developments are information-led Information requirements must be identified first and only then should a choice be made from the hardware and software available. Development of National Coding Standards within the Czech DRG System

Information from PAS How it is extracted Who has access to the data Uses of information Data for HRG grouping Development of National Coding Standards within the Czech DRG System

How data is extracted from PAS Standard statistical reports (Korner) KEPS Extracts Decision Support Extracts Development of National Coding Standards within the Czech DRG System

Who has access to the data (1) Internal Information department – Requests for information come from many sources within the hospital but it is best managed centrally as the Information Manager will have a sound knowledge and understanding of how the data is captured and its relevance to meeting their needs. Contracts department – Standard reports showing activity by specialty for each purchaser are created and updated as necessary by the information department but can be run as required to provide updates on activity performance for each purchaser against agreed contract targets. – This allows contract managers to take timely action in areas of over or under performance Development of National Coding Standards within the Czech DRG System

Who has access to the data (2) External DOH Hospital Information Branch – KEPS Extracts – Decision Support extracts as and when required relating to a particular aspect of service which they want to analyse on a regional basis and perhaps compare to regions in the rest of the UK e.g. day case rates for particular procedures Purchasers – Decision Support extracts directly from the Hospital but they also have access to the Regional database (data warehouse) at the DOH Development of National Coding Standards within the Czech DRG System

Uses of information Performance monitoring i.e. how we are performing against government targets such as numbers of patients in waiting lists by time waiting Capacity planning and analysis Casemix analysis Development of National Coding Standards within the Czech DRG System

Information extracted for HRG’s Regionally defined process which all Hospitals use Data extracted from PAS and transferred to SQL Decision Support database Business Object Report generated to provide the minimum data set for the HRG Grouper Software to analyse and assign the correct HRG Once HRG assigned by the Grouper, activity reports produced and provided to Hospital’s Finance Department to begin the process of costing each HRG Development of National Coding Standards within the Czech DRG System

And finally, the Minimum Data Set for HRG Grouping AgeSpecialty code (regional code e.g. 101 Urology) Sex Length of stay (episodic) Method of discharge code Primary Diagnosis Secondary diagnosis code 1 Secondary diagnosis code 2 Secondary diagnosis code 3 Secondary diagnosis code 4 Secondary diagnosis code 5 Primary operation code Secondary operation code 1 Secondary operation code 2 Secondary operation code 3 Secondary operation code 4 Patient classification Method of admission code (elective or non elective) Hospital (code) Ward (code) Consultant (code) Patients local ID Date primary operation Date Secondary operation 1 Date Secondary operation 2 Date Secondary operation 3 Date Secondary operation 4 – Just look at the importance of Coding ! Development of National Coding Standards within the Czech DRG System